4 “There is no doubt that the first appearance of the mammal, with his unexplained need to push his testicles out of their proper home into the air, made a mess of the three layered abdominal wall that had done the reptiles well for 200 million years”William Ogilvie

7 A common, established procedureOpen repair is the preferred operation for primary inguinal herniorrhaphy by 86% of surgeons in the US.Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in Surg Clin N Am 2003; 83:1045–51.GIST represent a subset of sarcomas (tumors of mesenchymal origin) that develops in the gastrointestinal (GI) tract and may spread within the abdomen.GIST are relatively rare neoplasms, representing less than 1% of all tumors of the GI tract; nonetheless, GIST are the most common mesenchymal malignancy of the GI tract.The peak incidence seems to occur between 40 and 60 years of age.Men and women are affected equally, and it is unusual to find GIST in patients younger than 40.Approximately 4500 to 6000 cases of GIST occur annually in the United States. The prevalence of GIST is higher than its incidence, because the clinical course of the disease can last for 10 to 15 years.The definition of GIST is evolving and recently has been identified as a distinct clinical and histopathologic entity. In the past, GIST often were underdiagnosed because of confusion over classification and similarities to other tumor types.Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol. 2002;33:Jemal A, Murray T, Ward E, et al. Cancer statistics CA Cancer J Clin. 2005;55:10-30.Joensuu H, Fletcher C, et al. Management of malignant gastrointestinal stromal tumours. Lancet Oncol. 2002;3:Miettinen M, Lasota J. Gastrointestinal stromal tumors (GISTs): definition, occurrence, pathology, differential diagnosis and molecular genetics. Pol J Pathol. 2003;54:3-24.Nilsson B, Bumming P, Meis-Kindblom JM, et al. Gastrointestinal stromal tumors: the incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era—a population-based study in western Sweden. Cancer. 2005;103:

8 Open herniorraphy Short learning curve Cheap Less chance of recurrenceCan be done under local anaesthetic

9 Laparoscopic repair is the technique safe? is the repair secure?are long-term morbidity rates better than in open repair?do patients return to normal activities and work earlier?and are there any additional benefits?

10 Is the technique safe? The EU Hernia Trialists CollaborationMeta-analysis of 34 eligible trials (RCTs) with a total of 6804 patients.Complications reduce with experienceLaparoscopic complications show a marked improvement between the early and late 1990s with an incidence of 5.6% and 0.5%, respectively (P < 0.001).Haematoma occurs more frequently after open surgery.Testicular injury and wound infection is more common after open repairEU Hernia Trialists Collaborative. Br J Surg 2000; 87: 860–7.

12 Are postop morbidity rates better?5-year follow-up of 400 patients treated with either Lichtenstein open mesh repair or TAPP repairthe incidence of permanent paraesthesia: 23% vs 3%groin pain 10% vs 2%all of the patients with pain and paraesthesia significant enough to affect their daily lives were in the open repair groupWellwood: Prospective randomized controlled trial of laparoscopic versus open inguinal hernia mesh repair: five year follow up. BMJ 326:1012, 2003

13 Do patients return to normal activities and work earlier?27 RCTs have considered the speed of recovery and return to work.24 of these report an earlier return to both activity and work in the laparoscopic groups comparedwith open repair.This is estimated to equate to an absolute difference of about 7 days in terms of time off work.McCormack K, Scott NW, Go PM, Ross S, Grant AM and EU HerniaTrialists Collaboration. Laparoscopic techniques versus opentechniques for inguinal hernia repair. Cochrane Databases SystemRev 2003(1); CD

14 Are there any additional benefits?Laparoscopic surgery allows bilateral hernias to berepaired through the same three small incisionsthere is no increase in postoperative pain or recovery timeThe same advantages are apparent in the repair of recurrent hernias particularly when the recurrence has occurred more than once

15 Is laparoscopic repair cost effective?Both laparoscopic and open techniques can be routinely performed as day cases in fit patientsSocietal costs due to quicker recovery and return to employment show clear advantages for the laparoscopic repair.Hospital Episode Statistics 2001/2

36 Weight loss - Treatment optionsLifestyle Modifications e.g. diet and exerciseAnti-obesity medications - Xenical® (Orlistat/Alli)Surgery (in suitable patients – NOCE, NIH criteria)Clearly, obesity has dramatic consequences for individuals and society.Fortunately, there are a variety of treatments available. Some have better outcomes than others.Diet and exercise, the typical recommended approach, are both important but when applied alone, they rarely result in long-term weight loss - just 5%-10% excess weight loss (EWL) on average [1,2,3].Newer treatments such as medications also lack long-term efficacy - achieving 5%-10% EWL on average [1,2,3,4].Bariatric surgery, of which there are several different types, is the only treatment option that has been demonstrated to be effective over the long term. More than 50% EWL sustained over 10 years) [2,3].References:1. Dixon JB, O'Brien PE. Health outcomes of severely obese type 2 diabetic subjects year after laparoscopic adjustable gastric banding. Diabetes Care. 2002;25(2):2. O'Brien PE, McPhail T, Chaston TB, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006;16(8):3. Fisher, BL, Schauer, P. Medical and surgical options in the treatment of severe obesity. American Journal of Surgery. 2002; Volume 184 (6B)4. Wierzbicki, A. Rimonabant: Endocannabinoid inhibition for the metabolic syndrome Int J Clin Pract. 2006;60(12):3636

37 Weight loss BARIATRIC SURGERY GASTRIC BALLOONHealthy Weight (BMI 18.5 to 24.9)Overweight (BMI 25 to 29.9)Obese (BMI 30 to 34.9)Severely Obese (BMI 35 to 39.9 )Morbidly Obese (BMI 40 or more)The ideal BMI lies in the range between 19 to 25.If your BMI is between 25 and 29.9, you are considered to be overweight.If it is between 30 and 39.9, you are obese.If your BMI is 40 or more, you are said to have morbid obesity.The term “morbid” obesity is used because this degree of excess weight may considerably reduce life expectancy and is associated with an increased risk of developing conditions or diseases such as diabetes, high blood pressure, joint problems, gallstones, stroke, heart disease, and psychosocial problems.BARIATRIC SURGERYGASTRIC BALLOON37

38 The Intragastric BalloonAn option between diets and surgical treatment38

39 Treating obesity with an Intragastric BalloonThe IntragastricBalloon is aweight-loss systemEducation aboutweight-lossThe balloonitselfThe intra-gastric balloon is a soft expandable balloon inserted in the stomach. The presence of the balloon in the stomach produces an early and prolonged sense of satiety. The device is designed to remain in the stomach for six months.Education and support is provided through regular scheduled meetings with the medical team to learn new principles to ensure long term success. The focus is on nutrition, exercise and healthy living.A multi-disciplinary approach to ensure long term weight loss. The Team of experts includes experienced weight loss professionals who will consult with you and design a program to help you successfully reach and maintain your weight-loss goals. The team can include your surgeon, GP, nutritionist, lifestyle coach, exercise trainer and psychologist.39

40 Who is suitable? Motivated, moderately obese adults.BMI of 27 and overPrepared to make changes in eating habits and lifestyle Willing to work with medical team and attend meetings.40

41 Step 3 Follow up Diet and changed eating habits ExerciseThe procedureStep 1AssessmentStep 2InsertionStep 3 Follow up Diet and changedeating habits ExerciseStep 4RemovalMaintainweight-lossOnce the balloon is removed, weight-loss can only be maintained if the patients adhere to their new lifestyle regime.41

42 Balloon removalRemoval of the balloon follows the same simple procedure as placement A tube is passed into the stomach and the balloon is deflated The deflated balloon is then removed through the mouth Patients can usually return home within hours42

43 Following the procedureRegular scheduled meetings with the team to continue education and support on new eating and exercise habitsThe balloon helps adjustment to reduced caloric intake by producing a feeling of satiety15-20 Kgs weight loss / 6 months43

44 Life after balloon removalBalloon removal after six months Keep practicing the principles Keep meeting with the team Nutrition, balance, exercise Motivation remains the key to successThe intragastric balloon will not be successful without commitment from the recipient. Motivation is key to long-term success.4444

45 Benefits of the intragastric balloon programmeNo surgery is requiredNo long-term use of pharmaceuticalsFeeling of satiety makes success more likely than other programmes10-20Kgs / 6 monthsThere are a number of advantages associated with treatment with an intragastric balloon. Not only does it avoid surgery but the programme of support that accompanies it support long-term success.4545

49 Intragastric balloon Possible indicationsWeight loss post “pregnancy obesity”> Woman should loose all the weight gain in pregnancy with breast feedingBut...It is not what we see in consecutive pregnancies49

50 Intragastric balloon Possible indications Aesthetics>“Preparing for special happenings”>“Psychological well being”>“ less risky than liposuction”50